|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
|
IP
|
$7,636.82
|
|
|
Service Code
|
APR-DRG 6911
|
| Min. Negotiated Rate |
$7,636.82 |
| Max. Negotiated Rate |
$7,636.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,636.82
|
|
|
LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA
|
Facility
|
IP
|
$27,586.47
|
|
|
Service Code
|
APR-DRG 6914
|
| Min. Negotiated Rate |
$27,586.47 |
| Max. Negotiated Rate |
$27,586.47 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,586.47
|
|
|
Lysis or excision of penile post-circumcision adhesions
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 54162
|
| Min. Negotiated Rate |
$293.87 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,544.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,799.36
|
| Rate for Payer: Dignity Health Senior |
$2,544.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,544.87
|
| Rate for Payer: Humana Medicare |
$2,544.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$293.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,544.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,835.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,002.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,206.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,206.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,799.36
|
| Rate for Payer: TriValley Medical Group Senior |
$2,544.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,817.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,799.36
|
| Rate for Payer: Vantage Medical Group Senior |
$2,544.87
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.98 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Adventist Health Commercial |
$89.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$239.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.54
|
| Rate for Payer: Blue Shield of California Commercial |
$277.83
|
| Rate for Payer: Blue Shield of California EPN |
$262.62
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.28
|
| Rate for Payer: Dignity Health Senior |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.93
|
| Rate for Payer: Heritage Provider Network Senior |
$276.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.85
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.96
|
| Rate for Payer: TriValley Medical Group Senior |
$178.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.98 |
| Max. Negotiated Rate |
$335.54 |
| Rate for Payer: Adventist Health Commercial |
$89.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.36
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.88
|
| Rate for Payer: Heritage Provider Network Senior |
$302.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.85
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
IP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-15
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.98 |
| Max. Negotiated Rate |
$335.54 |
| Rate for Payer: Adventist Health Commercial |
$89.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.36
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$241.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$302.88
|
| Rate for Payer: Heritage Provider Network Senior |
$302.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.85
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
|
|
MACITENTAN 10 MG TABLET [203952]
|
Facility
|
OP
|
$447.39
|
|
|
Service Code
|
NDC 66215-501-30
|
| Hospital Charge Code |
ERX203952
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$80.98 |
| Max. Negotiated Rate |
$380.28 |
| Rate for Payer: Adventist Health Commercial |
$89.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$239.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$307.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$380.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$246.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$335.54
|
| Rate for Payer: Blue Shield of California Commercial |
$277.83
|
| Rate for Payer: Blue Shield of California EPN |
$262.62
|
| Rate for Payer: Cash Price |
$201.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$290.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$380.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$380.28
|
| Rate for Payer: Dignity Health Senior |
$380.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$286.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$276.93
|
| Rate for Payer: Heritage Provider Network Senior |
$276.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$111.85
|
| Rate for Payer: Multiplan Commercial |
$335.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$178.96
|
| Rate for Payer: TriValley Medical Group Senior |
$178.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$380.28
|
| Rate for Payer: Vantage Medical Group Senior |
$380.28
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
|
IP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$125.96 |
| Rate for Payer: Adventist Health Commercial |
$33.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$115.38
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$113.70
|
| Rate for Payer: Heritage Provider Network Senior |
$113.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.99
|
| Rate for Payer: Multiplan Commercial |
$125.96
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [23233]
|
Facility
|
OP
|
$167.95
|
|
|
Service Code
|
NDC 49884-902-52
|
| Hospital Charge Code |
1743697
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$142.76 |
| Rate for Payer: Adventist Health Commercial |
$33.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$89.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$115.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$142.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$92.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$125.96
|
| Rate for Payer: Blue Shield of California Commercial |
$104.30
|
| Rate for Payer: Blue Shield of California EPN |
$98.59
|
| Rate for Payer: Cash Price |
$75.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$142.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$142.76
|
| Rate for Payer: Dignity Health Senior |
$142.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.96
|
| Rate for Payer: Heritage Provider Network Senior |
$103.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$80.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.99
|
| Rate for Payer: Multiplan Commercial |
$125.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$67.18
|
| Rate for Payer: TriValley Medical Group Senior |
$67.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$142.76
|
| Rate for Payer: Vantage Medical Group Senior |
$142.76
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Senior |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 51079-623-81
|
| Hospital Charge Code |
NDG10478
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.09
|
| Rate for Payer: Dignity Health Senior |
$1.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Vantage Medical Group Senior |
$1.09
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [10478]
|
Facility
|
IP
|
$1.23
|
|
|
Service Code
|
NDC 51079-623-82
|
| Hospital Charge Code |
1743480
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 6858500575
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 1000670013
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 1000670013
|
| Hospital Charge Code |
1712587
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [105730]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 6761810760
|
| Hospital Charge Code |
1712588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [105730]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 6761810760
|
| Hospital Charge Code |
1712588
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
MAGNESIUM CHLORIDE ORAL SOLUTION COMPOUND 2 MEQ/ML [4080294]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-94
|
| Hospital Charge Code |
1715089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
MAGNESIUM CHLORIDE ORAL SOLUTION COMPOUND 2 MEQ/ML [4080294]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 9994-0802-94
|
| Hospital Charge Code |
1715089
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [4712]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0869-0166-38
|
| Hospital Charge Code |
1719128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [4712]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 69452-390-98
|
| Hospital Charge Code |
1719128
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [4712]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 69452-390-98
|
| Hospital Charge Code |
1719128
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [4712]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0869-0166-38
|
| Hospital Charge Code |
1719128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
